Provider Demographics
NPI:1932810355
Name:BROOKS, MARYLON WILLETTE (LPN)
Entity Type:Individual
Prefix:
First Name:MARYLON
Middle Name:WILLETTE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 W LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-3510
Mailing Address - Country:US
Mailing Address - Phone:815-908-9407
Mailing Address - Fax:
Practice Address - Street 1:2170 W NAVAJO DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-0010
Practice Address - Country:US
Practice Address - Phone:815-908-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043110870164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty